Provider Demographics
NPI:1619461282
Name:PEACOCK CATHCART, ALEXANDRA YANIVA (DMD)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:YANIVA
Last Name:PEACOCK CATHCART
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:YANIVA
Other - Last Name:PEACOCK-VILLADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:190 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-874-1028
Mailing Address - Fax:207-842-2963
Practice Address - Street 1:110 AUBURN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2128
Practice Address - Country:US
Practice Address - Phone:207-797-7433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN46451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice